Benign large and giant rectal polyps: Value and limits of the endoscopic treatment

Large colorectal polyps are sessile or pedunculated lesions greater than 3 cm in size. Sixty-five patients, with 65 of such lesions, were retrospectively evaluated over a 12-year period; 21 were submitted to surgery or palliative treatments for malignancy or excessive extension and 1 dropped-out. The remaining patients had 43 lesions, ranging from 3 to 10 cm in size and featuring 42 adenomas with various degree of dysplasia, and were treated with endoscopic therapy until complete polypectomy and macroscopic eradication was obtained. At follow-up (mean 688 ± 109.8 days, range 30-2860) 28 patients persisted as disease-free, 3 dropped-out and 15 (34.8%) developed one or more recurrences. Among the latter, 10 were endoscopically re-treated achieving a definitive eradication, 3 were drop-outs and 2 were submitted to surgery (1 for multiple recurrences and 1 for histological evolution of the recurrent lesion). Recurrences were significantly more frequent (p ≤ 0.01) among giant lesions (≥ 6 cm in size) than smaller lesions (from 3 to 5.9 cm in size), but the achievement of definitive eradication was not significantly different in the two groups. Thus, 35 out of 43 patients (81.4%) in which initial macroscopic eradication was obtained were definitively cured by endoscopic therapy alone. We conclude that endoscopic polypectomy (usually with piecemeal technique) can be considered the first-choice therapeutic approach for the majority of benign large and giant rectal polyps, with a minimal rate (4.6%) of minor complications. However, surgery reserves an unreplaceable therapeutic role for very extensive sessile lesions and for cases of untreatable multiple recurrences or suspected degeneration.